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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200176
Report Date: 11/29/2023
Date Signed: 11/29/2023 12:22:24 PM

Document Has Been Signed on 11/29/2023 12:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:S.M. CARE HOME 1FACILITY NUMBER:
079200176
ADMINISTRATOR:HENRY LIMFACILITY TYPE:
735
ADDRESS:18 VIGNOLA COURTTELEPHONE:
(925) 625-3888
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Henry Lim, AdministratorTIME COMPLETED:
12:30 PM
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On 11/29/2023 at 9:10 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Henry Lim and explained the purpose of the visit. he facility’s fire clearance was approved for 6 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured within range 105-120 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 08/31/2023. Emergency Disaster Drill (Earthquake) was last conducted on 10/28/2023. Fire drill was last conducted on 07/29/2023. First aid kit was observed to be complete.


Report continues on 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: S.M. CARE HOME 1
FACILITY NUMBER: 079200176
VISIT DATE: 11/29/2023
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At 9:25 AM, LPA reviewed 6 of 6 client records. At 10:20 AM, LPA reviewed 6 staff records and 6 of 6 have current first aid training and associated to the facility. At 11:18 AM, LPA reviewed a sample of 6 of 6 client medications.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/13/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 D Emergency Disaster Plan




No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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